Elsevier

International Journal of Cardiology

Volume 343, 15 November 2021, Pages 114-121
International Journal of Cardiology

Psoriasis and its impact on the clinical outcome of patients with pulmonary embolism

https://doi.org/10.1016/j.ijcard.2021.08.042Get rights and content

Highlights

  • Psoriasis is accompanied by an increased risk for venous thromboembolism (VTE).

  • Psoriasis was associated with unfavorable cardiovascular-risk and VTE-risk profile in PE patients.

  • PE patients with psoriasis were younger than those PE patients without psoriasis.

  • In-hospital mortality was lower in psoriatic PE patients mainly driven by younger age.

  • Our findings contribute evidence for relevant systemic manifestation of psoriasis.

Abstract

Background

An increased risk for venous thromboembolism (VTE), comprising pulmonary embolism (PE) and deep venous thrombosis, has been reported in psoriasis patients. The impact of psoriasis on prognosis of VTE patients is widely unknown.

Methods

Hospitalized PE patients were stratified for psoriasis and the impact of psoriasis on outcome was investigated in the German nationwide inpatient sample of the years 2005–2017.

Results

Overall, 1,076,384 hospitalizations of PE patients (53.7% females, median age 72.0 [60.0–80.0] years) were recorded in Germany 2005–2017. Among these, 3145 patients had psoriasis (0.3%). Psoriatic PE patients were younger (68.0 [57.0–76.0] vs. 72.0 [60.0–80.0] years,P < 0.001) and more often male (64.1% vs. 46.3%,P < 0.001). The prevalence of VTE risk factors, traditional cardiovascular risk factors and cardiovascular comorbidities was higher in psoriatic than in non-psoriatic individuals.

Psoriatic PE patients showed a lower in-hospital case-fatality rate (11.1% vs. 16.0%,P < 0.001), confirmed by logistic regressions showing an independent association of psoriasis with reduced case-fatality rate (OR 0.73 [95%CI 0.65–0.82],P < 0.001), despite higher prevalence of pneumonia (24.8% vs. 23.2%,P = 0.029). Psoriasis was an independent predictor for gastro-intestinal bleeding (OR 1.35 [95%CI 1.04–1.75],P = 0.023) and transfusion of blood constituents (OR 1.23 [95%CI 1.11–1.36],P < 0.001).

Conclusions

PE patients with psoriasis were hospitalized in median four years earlier than those without. Although psoriasis was associated with an unfavorable cardiovascular-risk and VTE-risk profile in PE patients, our data demonstrate a lower in-hospital mortality in psoriatic PE, which might be mainly driven by younger age. Our findings may improve the clinical management of these patients and contribute evidence for relevant systemic manifestation of psoriasis.

Translational perspective

An increased risk for venous thromboembolism (VTE), comprising pulmonary embolism (PE) and deep venous thrombosis, has been reported in psoriasis patients, but the impact of psoriasis on prognosis of VTE patients is widely unknown. PE patients with psoriasis were younger and psoriasis was associated with an unfavorable cardiovascular-risk and VTE-risk profile. In-hospital mortality was lower in psoriatic PE patients, which might be mainly driven by younger age. Our findings improve the clinical management of PE patients and contribute evidence for relevant systemic manifestation of psoriasis.

One sentence summary

Psoriasis with chronic inflammation promotes PE development, is associated with an unfavorable cardiovascular and VTE-risk profile, but lower in-hospital mortality.

Introduction

Venous thromboembolism (VTE), comprising deep venous thrombosis and pulmonary embolism (PE), is a common medical problem with a high morbidity and mortality worldwide [1], [2]. Major trauma, surgery, immobilization, cancer and thrombophilia are well recognized traditional risk factors for VTE [1], [3]. Up to now chronic inflammation is not included among the traditional risk factors for VTE, but various inflammatory cytokines are known to promote coagulation by an up-regulation of procoagulants and a down-regulation of the anticoagulant and fibrinolytic system [3]. Several chronic inflammatory diseases such as rheumatoid arthritis, systemic lupus erythematosus, Sjogren syndrome, systemic sclerosis and dermatomyositis as well as polymyositis were associated with an increased risk of VTE [4], [5], [6], [7], [8].

While studies confirmed an increased cardiovascular morbidity and mortality in psoriatic patients [9], [10], data about the influence of psoriasis on the development and on the prognosis of VTE are inconclusive [3]. Some studies showed that psoriasis might be accompanied by an increased risk of VTE [3], [4], [11], but this finding was not confirmed in other studies [5]. Disease severity and additional factors may affect the development of VTE in psoriasis patients. In this context, a Danish cohort study demonstrated that the relative risk for VTE was highest in young psoriatic patients with severe psoriasis [11]. Nevertheless, the impact of psoriasis on the cardiovascular profile and on the outcomes of VTE patients and especially PE patients is not well examined. Since adequate management of public health as well as health care service planning requires reliable information about disease incidence, hospitalizations, adverse events due to diseases and interactions between diseases, data about an impact of two common diseases such as VTE and psoriasis are important to allow prospective health care planning and patient-management [12], [13].

Thus, we aimed 1) to compare PE patients with and without psoriasis in particular regarding the cardiovascular profile and VTE risk factors, 2) to investigate their temporal trends and 3) to analyze the impact of psoriasis on in-hospital outcome of PE in a large nationwide inpatient sample.

Section snippets

Data source

We used the German nationwide inpatient statistics (diagnosis related groups [DRG] statistic) for our present study (source: RDC of the Federal Statistical Office and the Statistical Offices of the federal states, DRG Statistics 2005–2017, and own calculations). All treatment data of inpatient cases in Germany (processed according to the DRG system) are gathered by the Federal Statistical Office of Germany (Statistisches Bundesamt, Wiesbaden, Germany). Patients' diagnoses are coded according to

Results

Overall, 1,076,384 hospitalizations of PE patients (53.7% females, median age 72.0 [60.0–80.0] years) were recorded in Germany between 2005 and 2017 (Flowchart is presented in Fig. S1 in the Supplementary material, Table 1). Among these, 3145 were coded with psoriasis (0.3%). During hospitalization, 172,287 patients died (16.0%). The median length of in-hospital stay was 10 (6–16) days.

The total numbers of PE patients with psoriasis increased from 205 in the year 2005 to 279 in the year 2017 (β

Discussion

Psoriasis is a common chronic skin disease mediated by inflammatory cytokines with a prevalence of approximately 1.5–3.0% in the western populations [14], [15], [16], [17]. Evidence about the impact of psoriasis on cardiovascular profile and on the in-hospital outcome of PE patients are sparse. Since adequate management of public health as well as health care service planning requires reliable information about disease incidence, hospitalizations, adverse events due to diseases and interactions

Limitations

Some limitations merit consideration: First, the study results are based on ICD and OPS discharge codes of hospitalized patients, which might have led to an under-reporting / under-coding, particularly in more severe PE cases with early decease. Second, data about anticoagulant treatment and from later follow-up after hospitalization were not available. Third, in only 0.3% PE hospitalizations psoriasis was coded, which is certainly under the known incidence for psoriasis in Europe (2–3%).

Conclusions

In total, only 0.3% of all PE hospitalizations in Germany were coded additionally with the skin disease psoriasis. PE events in psoriatic patients occurred in median 4 years earlier in life than in those PE patients without psoriasis. Psoriasis was associated with unfavorable cardiovascular profile with higher prevalence of classical CVRF and cardiovascular comorbidities as well as traditional VTE risk factors such as surgery and thrombophilia.

Our data demonstrates a lower in-hospital mortality

Funding

SKa is funded by the German Research Foundation (DFG KA 4035/1-1) and by the CRC/Transregio 156. SKa receive funding from the Boehringer Ingelheim Foundation “Novel and Neglected Cardiovascular Risk Factors: Molecular Mechanisms and Therapeutic Implications” and the Federal Ministry of Education and Research (BMBF 01EO1503). TG and TM are PI of the DZHK (German Center for Cardiovascular Research), Partner Site Rhine-Main, Mainz, Germany. KS is funded by the German Research Foundation (CRC

Author contributions

Karsten Keller and Lukas Hobohm were involved in the conception and design of the study and analysis and interpretation of the data; all authors contributed in drafting and revising the paper critically for intellectual content and gave final approval of the version to be published and agree to be accountable for all aspects of the work.

Declaration of Competing Interest

KK, MAO, SKa, CE-K and TM reported no conflict of interest. LH reports having received lecture honoraria from MSD. SKo reports having received consultancy and lecture honoraria from Bayer, Boehringer Ingelheim, Daiichi-Sankyo, MSD and Pfizer – Bristol-Myers Squibb; and institutional grants from Actelion, Bayer, Boehringer Ingelheim, Daiichi-Sankyo and Pfizer – Bristol-Myers Squibb. KS reports having received consultancy and lecture honoraria from Actelion, Pfizer and Novartis. TG has received

Acknowledgements

We thank the Federal Statistical Office of Germany (Statistisches Bundesamt, DEStatis) for providing the data/results and the kind permission to publish these data.

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  • Cited by (0)

    1

    K.K. und L.H. contributed equally and share first authorship.

    2

    K.S. and T.G. contributed equally and share last authorship.

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